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Release of Information Consent Form

Enhanced Divorce Mediation & Counseling

Kayla Flowers LISW-S

8228 Mayfield Road, Suite 2A-4

Chesterland, OH 44026

440-220-5905

kflowers@edmc-oh.net

Client Information

Birthday
Month
Day
Year

Disclosure Consent

The following person/organization is authorized to:

Name of person/organization receiving consent:

Enhanced Divorce Mediation & Counseling

Kayla Flowers LISW-S

440-220-5905

kflowers@edmc-oh.net

Purpose of disclosure:
Type of information to be disclosed:
Amount of information to be disclosed:
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Signature of Enhanced Divorce Mediation & Counseling staff ONLY




Date:

This authorization expires:
In 30 days
In 3 months
In 6 months
In 12 months
Other

This authorization is subject to written revocation at any time except to the extent the organization or person who is to make the disclosure has already acted in reliance on it. Please note if revoke this consent at any time, send an email to kflowers@edmc-oh.net stating that you revoke consent as of a specific date.

Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client.  Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 [HIPAA], 45 C.F.R., parts 160 and 164. [These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.]

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